Evaluating the international standards gap for the use of acupuncture needles by physiotherapists and chiropractors: A policy analysis

Autoři: Nadine Ijaz aff001;  Heather Boon aff001
Působiště autorů: Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada aff001
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0226601



Acupuncture needles have become an increasingly-popular treatment tool used by multiple health professions. However, the World Health Organization (WHO)’s 1999 training guidelines for acupuncture address only medical doctors and licensed acupuncturists, leaving a gap as to appropriate training standards for other professions.

Aims and methods

With reference to an extensive document analysis, and interviews with seventeen acupuncture educators from across several professions in Ontario, Canada, this work uses a critical qualitative policy analytic approach to: a) present a comprehensive account of statutory training requirements for acupuncture-needling physiotherapists and chiropractors in the United States, Canada, and Australia; and b) evaluate competing stakeholder discourses pertaining to recent related controversies.


A wide range of educational requirements are evident across the jurisdictions under study (most below the 200-hour WHO guideline for physicians); and there is considerable disagreement among stakeholders as to what constitutes sufficient training in various forms of acupuncture, including ‘dry needling’. Organizations defending brief post-graduate training for needling physiotherapists and chiropractors are generally associated with these two professions, and contend that their ‘dry needling’ practices differ substantially from traditional acupuncture. Characterizing such brief training as insufficient, opportunistic and unsafe, and ‘dry needling’ as a subset of acupuncture practice, are the voices of all acupuncture educators interviewed, as well as professional organizations representing physicians, licensed acupuncturists, and some physiotherapists and chiropractors.

Discussion and conclusion

Critiquing claims on both sides of the debate, this work calls for the development of independent, international safety-geared training guidelines that explicitly address the recent, evidence-informed trend towards biomedicalized acupuncture needling. Findings also suggest a need for additional research regarding the current shift towards overlapping—rather than exclusive—health professional practice scopes in industrialized countries.

Klíčová slova:

Acupuncture – Adverse events – Chiropractic – Medical doctors – Physicians – Physiotherapy – Professions – Traditional medicine


1. World Health Organization. Guidelines on basic training and safety in acupuncture 1999. http://apps.who.int/medicinedocs/en/d/Jwhozip56e/.

2. Saks M. Professions and the public interest: medical power, altruism and alternative medicine. London: Routledge; 1995.

3. Dommerholt J. Professional controversies and dry needling. In: Dommerholt J, de las Penas C, editors. Trigger Point Dry Needling: an evidence and clinical-based approach: Churchill Livingstone; 2013. p. 59–69.

4. Brady S, McEvoy J, Dommerholt J, Doody C. Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. Journal of Manual and Manipulative Therapy. 2014.

5. World Health Organization. Acupuncture: review and analysis of reports on controlled clinical trials 2002 [June 7, 2018]. http://www.iama.edu/OtherArticles/acupuncture_WHO_full_report.pdf.

6. Thomas K, Nicholl J, Coleman P. Use and expenditure on complementary medicine in England: a populaion based survey. Comp Ther Med. 2001;9:2–11.

7. Hopton A, Curnoe S, Kanaan M, MacPherson H. Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey. BMJ Open. 2012;2(e000456):1–11.

8. Barnes P, Bloom B, Nahin R. Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Report. 2008;12(December 10, 2008):1–24.

9. Statistics Canada. Health reports: Use of alternative health care. The Daily. 2005;15(3).

10. Quan H, Lai D, Johnson D, Verhoef M, Musto M. Complementary and alternative medicine use among Chinese and white Canadians. Can Fam Physician. 2008;54:1563–9. 19005129

11. Xue C, Zhang A, Lin V, Da Costa C, Story D. Complementary and alternative medicine use in Australia: A national population-based survey. J Alt Comp Med. 2007;13(6):643–50.

12. Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events related to acupuncture. JAMA. 1998;280(18):1563.

13. MacPherson H, Scullion A, Thomas K, Walters S. Patient reports of adverse events associated with acupuncture treatment: a prospective national survey. Qual Saf Health Care. 2004;13:349–55. doi: 10.1136/qshc.2003.009134 15465938

14. MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ. 2001 323:486–7. doi: 10.1136/bmj.323.7311.486 11532841

15. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ. 2001;323:485–6. doi: 10.1136/bmj.323.7311.485 11532840

16. Melchart D, Weidenhammer W, Streng A, Reitmayr s, Hoppe A, Ernst E, et al. Prospective investigation of adverse effects of acupuncture in 97 773 patients. Arch Intern Ned. 2004;164:104–5.

17. Witt C, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplmentarmed. 2009;16:91–7.

18. Odsberg A, Schill U, Haker E. Acupuncture treatment: side effects and complications reported by Swedish physiotherapists. Comp Ther Med. 2001;9:17–20.

19. Chan M, Wu X, Wu J, Wong S, Chung V. Safety of acupuncture: Overview of systematic reviews. Nature. 2017;7(3369):1–11. doi: 10.1038/s41598-017-03272-0 28611366

20. Bensoussan A, Myers S, Carlton A. Risks associated with the practice of traditional Chinese medicine. Arch Fam Med. 2000;9:1071–8. doi: 10.1001/archfami.9.10.1071 11115210

21. Yamashita H, Tsukayama H, Hori N, Kimura T, Tanno Y. Incidence of adverse reactions associated with acupuncture. J Alt Comp Med. 2000;6(4):345–50.

22. World Health Organization. WHO guidelines on basic training and safety in chiropractic. 2005.

23. Organization) WWH. Benchmarks for training in traditional / complementary and alternative medicine 2016 [March 16, 2016]. http://www.who.int/medicines/areas/traditional/trm_benchmarks/en/.

24. World Confederation for Physical Therapy. World Health Organization 2019 [February 5, 2019]. https://www.wcpt.org/node/27544.

25. Organization WH. World Confederation for Physical Therapy, London, UK 2019 [February 5, 2019]. https://www.who.int/workforcealliance/members_partners/member_list/wcpt/en/.

26. Kohut S, Larmer P, Johnson G. Western acupuncture education for New Zealand physiotherapists. Physical Therapy Reviews. 2011;16(2):106.

27. Amaro J. Acupuncture Statistics…very interesting! Dynamic Chiropractic. 1997;15(25).

28. Birch S. Reflections on the German Acupuncture studies. Journal of Chinese Medicine. 2007;83:12–7.

29. Canadian Alliance of Regulatory Bodies for Traditional Chinese Medicine Practitioners and Acupuncturists. Blueprint for the Pan-Canadian Written Examinations for Traditional Chinese Medicine Practitioners, Acupuncturists and Herbalists 2015 [June 7, 2018]. https://www.ctcmpao.on.ca/resources/forms-and-documents/CARB_TCMPA_Blueprint_Written_Exam_March_2015.pdf.

30. National Certification Commission for Acupuncture and Oriental Medicine. Are you eligible? 2018 [April 25, 2018]. http://www.nccaom.org/eligibility-to-sit-for-examinations/.

31. Zheng Z. Acupuncture in Australia: regulation, education, practice, and research. Integrative Medicine Research. 2014;3(3):103–10. doi: 10.1016/j.imr.2014.06.002 28664085

32. Wardle J, Adams J, Sibbrett D. Acupuncture in Australian general practice: trends in reimbursed acupuncture services from 1995 to 2011. Acupunct Med. 2013;31(45–50).

33. Australian Health Practitioner Regulation Agency. Approved Programs of Study 2015 [July 22, 2016]. http://www.ahpra.gov.au/Education/Approved-Programs-of-Study.aspx?ref=Medical%20Practitioner&type=Endorsement.

34. Acupuncture Foundation of Canada. Regulatory Bodies 2014 [April 11, 2014]. http://www.afcinstitute.com/Links/RegulatoryBodies/tabid/288/Default.aspx.

35. World Health Organization. Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review 2001 [February 10, 2014]. http://apps.who.int/medicinedocs/pdf/h2943e/h2943e.pdf.

36. Lin K, Tung C. The regulation of the practice of acupuncture by physicians in the United States. Med Acupunc. 2017;29(3):121–7.

37. American Academy of Medical Acupuncture. American Academy of Medical Acupuncture homepage 2014 [April 2, 2014]. http://www.medicalacupuncture.org/.

38. International Acupuncture Association of Physical Therapists. Guidelines for safe acupuncture and dry needling practice. 2016.

39. Acupuncture Association of Chartered Physiotherapists. AACP Training Overview 2018 [June 7, 2018]. https://www.aacp.org.uk/page/24/aacp-training-overview.

40. Irish Society of Chartered Physiotherapists. Guidelines for dry needling practice 2012 [June 7, 2018]. http://www.colfisiocv.org/sites/default/files/Guidelines%20for%20Dry%20Needling%20Practice%20ISCP%202012.pdf.

41. Australian Society of Acupucture Physiotherapists. Guidelines for safe acupuncture and dry needling practice 2006 [June 7, 2018]. https://www.dryneedling.com.au/wp-content/uploads/2016/04/asap-safety-guidelines-2007.pdf.

42. Australian Society of Acupuncture Physiotherapists. Guidelines for safe acupuncture and dry needling practice 2013 [Sept. 17, 2017]. combinedhealth.com.au/webfiles/ASAP_Guidelines_2013.pdf.

43. Federation of State Boards of Physical Therapy. Analysis of competencies for dry needling by physical therapists Alexandria, VA2015 [July 16, 2016]. http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Dry_Needling/AnalysisCompetenciesforDryNeedlingbyPT.pdf.

44. National Board of Chiropractic Examiners. NBCE—Acupuncture Exam 2015 [July 16, 2016]. http://mynbce.org/prepare/acupuncture/.

45. American Board of Chiropractic Acupuncture. State requirements for chiropractic acupuncture 2016 [July 16, 2016]. http://councilofchiropracticacupuncture.org/state-requirements.html%20-%20not.

46. Johnson G, Skinner M, Stephen R. Lessons to be learned: A retrospective analysis of physiotherapy injury claims. J Orthop Sports Phys Ther. 2012;42(8):698–704. doi: 10.2519/jospt.2012.3877 22711215

47. Ijaz N. Regulating traditional medicine professionals in the public interest: A case study of Chinese medicine and acupuncture regulation in Ontario, Canada. PhD Thesis, University of Toronto, TSpace. 2017.

48. Ijaz N, Boon H. Safety as ‘boundary object’: the case of acupuncture and Chinese medicine regulation in Ontario, Canada. In: Brosnan C, Violanto P, Danell J-A, editors. Complementary and alternative medicine: Knowledge production and social transformation: Palgrave Macmillan; 2018.

49. Baxter P, Jack S. Qualitative case study methodology: study design and implementation for novice researchers. TQR. 2008;13(4):544–59.

50. Stake R. The art of case study research. Thousand Oaks: Sage; 1995.

51. Howarth D. Power, discourse, and policy: articulating a hegemony approach to critical policy studies. Critical Policy Studies. 2009;3(3–4):309–35.

52. Diem S, Young M, Welton A, Cumings Mansfied K, Lee P-L. The intellectual landscape of critical policy studies. International Journal of Qualitative Studies in Education. 2014;27(9):1068–90.

53. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nursing and Health Sciences. 2013;15:398–405. doi: 10.1111/nhs.12048 23480423

54. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

55. Fairclough N. Critical discourse analysis and critical policy studies. Critical Policy Studies. 2013;7(2):177–97.

56. Bacchi C. Analysing policy: What’s the problem represented to be? Frenchs Forest, New South Wales: Pearson Australia; 2009.

57. Houghton C, Casey D, Shaw D, Murphy K. Rigour in qualitative case-study research. Nurse Researcher. 2013;20(4):12–7. doi: 10.7748/nr2013. 23520707

58. Shenton A. Strategies for ensuring trustworthiness in qualitative research projects. Education for Information. 2004;22:63–75.

59. Berger R. Now I see it, now I don’t: researcher’s position and reflexivity in qualitative research. Qualitative Research. 2015;15(2):219–34.

60. Chiropractors’ Association of Saskatchewan. Chiropractic Regulatory ByLaws 2016 [July 26, 2016]. http://www.saskchiropractic.ca/doc/Regulatory%20Bylaws%20May%209%2C%202016.pdf.

61. College of Chiropractors of Ontario. Standard of Practice: Acupuncture, S-017 2009 [26 July 2016]. http://www.cco.on.ca/site_documents/S-017.pdf.

62. Chiropractic Board of Australia. Endorsement 2015 [July 22, 2016]. http://www.chiropracticboard.gov.au/Registration/Endorsement.aspx.

63. American Physical Therapy Association. State Advocacy 2018 [June 17, 2018]. https://www.apta.org/StateAdvocacy/.

64. Myopain Seminars. New developments and rulings about dry needling by U.S. state boards 2018 [June 17, 2018]. http://myopainseminars.com/resourcesnews-rulings/.

65. College of Physiotherapists of Manitoba. Practice Statement 4.6: Acupuncture and intramuscular dry needle therapy. 2006.

66. College of Physiotherapists of New Brunswick. Requirements for physiotherapist registration 2010 [July 26, 2016]. http://www.cptnb.ca/Documents/New_Applicants_July_2010_E_to_WEB.pdf.

67. College of Physiotherapists of Ontario. Performance of authorized activities 2011 [April 2, 2014]. http://www.collegept.org/Assets/registrants’guideenglish/standards_framework/standards_practice_guides/ST_Performance_of_%20Authorized_Activities_Standard_EN_120905.pdf.

68. College of Physiotherapists of Ontario. Controlled Acts and Other Restricted Activities Standard 2016 [June 7, 2018]. https://www.collegept.org/rules-and-resources/controlled-acts-and-other-restricted-activities.

69. Nova Scotia College of Physiotherapists. Practice Standard: Acupuncture 2014 [July 26, 2016]. http://nsphysio.com/resources/Acupuncture+Standard+May2014.pdf.

70. Prince Edward Island College of Physiotherapists. Acupuncture policy 2016 [July 27, 2016]. http://www.peicpt.com/sitefiles/File/Overview/AcupuncturePolicy.pdf.

71. Saskatchewan College of Physican Therapists The Physical Therapists Act 2001 [July 27, 2016]. http://www.qp.gov.sk.ca/documents/Bylaws/SCPT/August10,2001.pdf.

72. College of Physical Therapists of British Columbia. Practice Standard Number 10: Acupuncture and dry needling for physical therapists 2013 [April 2, 2014]. http://cptbc.org/wp-content/uploads/2013/10/PracticeStandards10.pdf.

73. Physiotherapy Board of Australia. Fact sheet: Acupuncture 2013 [July 22, 2016]. http://www.physiotherapyboard.gov.au/documents/default.aspx?record=WD12%2F8377%5Bv2%5D&dbid=AP&chksum=bMJqablrHj6q2nkqblYokw%3D%3D.

74. American Medical Association. AMA adopts new policies on final day of annual meeting 2016 [July 15, 2016]. http://www.ama-assn.org/ama/pub/news/news/2016/2016-06-15-new-policies-annual-meeting.page.

75. American Academy of Medical Acupuncture. AAMA Policy on Dry Needling 2017 [May 2, 2018]. http://www.medicalacupuncture.org/Portals/2/PDFs/DryNeedlingPolicyMar2017.pdf.

76. American Academy of Physical Medicine and Rehabilitation. AAMP&R Position on Dry Needling 2012 [7 June 2018]. https://www.aapmr.org/docs/default-source/advocacy/aapm-amp-r-resolution-and-positition-statement-on-dry-needling.pdf?sfvrsn=0.

77. American Society of Acupuncturists. ASA Position on Dry Needling 2016 [May 3, 2018]. https://acucol.com/resources/Documents/American%0Society%0of%0Acupuncturists%0Position%0on%0Dry%0Needling%0_9_14_16.pdf

78. National Certification Commission for Acupuncture and Oriental Medicine. NCCAOM and the NCCAOM Academy of Diplomates Dry Needling Position 2017 [June 7, 2018]. http://www.nccaom.org/wp-content/uploads/pdf/NCCAOM%20Dry%20Needling%20Position%20Statement.pdf.

79. American Association of Acupuncture and Oriental Medicine. AAAOM Position Statement on Trigger Point Dry Needling (TDN) and Intramuscular Manual Therapy (IMT) 2012 [May 2, 2018]. http://www.aaaomonline.org/Dry-Needling-Position-Paper.

80. American Traditional Chinese Medicine Association. Position letter on dry needling 2017 [May 2, 2018]. http://www.nccaom.org/wp-content/uploads/pdf/ATCMA%20Position%20Letter%20on%20Dry%20Needling.pdf.

81. Council of Colleges of Acupuncture and Oriental Medicine. Position on Dry Needling 2011 [Sept. 20, 2017]. http://www.ccaom.org/downloads/CCAOM_Position_Paper__May_2011_Update.pdf.

82. American Board of Chiropractic Acupuncture. CCA Policy Statement on Dry-Needling 2015 [Sept. 17, 2017]. http://americanboardofchiropracticacupuncture.org/position_papers/dry-needling.html.

83. Court of Appeals of the State of Oregon. Oregon Association of Acupuncture and Oriental Medicine v. Board of Chiropractic Examiners, A148924. Court of Appeals of the State of Oregon, 2014.

84. American Association of Acupuncture and Oriental Medicine. Congratulations to WEAMA for protecting Washington state acupuncturists and public safety 2016 [July 25, 2016]. https://www.aaaomonline.org/news/274059/Congratulations-to-WEAMA-for-protecting-Washington-State-acupuncturists-and-public-safety-.htm.

85. State of Washington. Senate Bill 6374, S-3546.1 2016 [July 25, 2016]. http://lawfilesext.leg.wa.gov/biennium/2015-16/Pdf/Bills/Senate%20Bills/6374.pdf.

86. State of New Jersey. Re: 13-0024-Scope of Physical Therapy Practice—Dry Needling 2017 [September 17, 2017]. https://www.taoa.org/wp-content/uploads/2017/02/Dry-Needling-opinion-NJ-AG-2.9.17.pdf.

87. Ijaz N, Boon H, Muzzin L, Welsh S. State risk discourse and the regulatory preservation of traditional medicine knowledge: the case of acupuncture in Ontario, Canada. Social Science and Medicine 2016;170:97–105. doi: 10.1016/j.socscimed.2016.08.037 27768943

88. Janz S, Adams J. Acupuncture by another name: dry needling in Australia. Australian Journal of Acupuncture and Chinese Medicine. 2011;6(2):3–11.

89. Occupational Therapy Board of Australia. Acupuncture 2015 [May 1, 2018]. http://www.occupationaltherapyboard.gov.au/News/Newsletters/November-2015.aspx%20-%20acupuncture.

90. Chiropractic Board of Australia. Chiropractic Board of Australia News 2014 [May 1, 2018]. http://www.chiropracticboard.gov.au/documents/default.aspx?record=WD14%2f14542&dbid=AP&chksum=2dhZ6rIJrJO1xwsWt%2bXP1w%3d%3d.

91. Wardle J, Weir M, Marshall B, Archer E. Regulatory and legislative protections for consumers in complementary medicine: Lessons from Australian policy and legal developments. Eur J Int Med. 2014. doi: http://dx.doi.org/10.1016/j.eujim.2014.03.008.

92. American Physical Therapy Association. Physical therapists and the performance of dry needling: an educational resource paper: APTA Department of Practice and and APTA State Government Affairs; 2012 [July 16, 2016]. http://handsonseminars.com/APTADryNeedlingResourcePaper.pdf.

93. Larson B. Dry needling by chiropractic physicians in Alaska: A position statement from the current Alaska state board of chiropractic examiners 2018 [May 2, 2018]. https://www.commerce.alaska.gov/web/portals/5/pub/CHI_DryNeedling.pdf.

94. Kalichman L, Vulfsons S. Dry Needling in the Management of Musculoskeletal Pain. J Am Board Fam Med. 2010;23(5):640–6. doi: 10.3122/jabfm.2010.05.090296 20823359

95. Brown C. Review of stakeholder input: "Dry needling" use by Arizona licensed physical therapists -1 2013 [June 7, 2018]. https://ptboard.az.gov/sites/default/files/files/dryneedlingbyPT3.pdf.

96. Zhou K, Ma Y, Brogan M. Dry needling versus acupuncture: the ongoing debatae. Acupunct Med. 2015;33:485–90. 26546163

97. Pew Health Professions Commission. Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century. San Fransisco: CA: Pew Health Professions Commission, 1995.

98. World Health Organization. Traditional, complementary and integrative medicine 2018 [May 15, 2018]. http://www.who.int/traditional-complementary-integrative-medicine/en/.

99. Ijaz N, Boon H, Welsh S, Meads A. Supportive but ‘worried’: perceptions of naturopaths, homeopaths and Chinese medicine practitioners through a regulatory transition in Ontario, Canada. BMC Complem Altern M. 2015;15:312–25.

100. Dower C, Moore J, Langelier M. It is time to restructure health professions scope-of-practice regulations to remove barriers to care. Health Affairs. 2013;11:1971–6.

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